By Lambert Strether of Corrente.
Single payer advocates tend to frame the obvious sanity and humanity of their policy proposal as “Medicare for All,” which would be great if “Medicare” meant Canadian Medicare, and not American Medicare, which is suffering from a tenacious neoliberal infestatation and hence, as readers periodically point out to to us, is becoming increasingly crapified. (There’s none of this “free at the point of care” nonsense that curses the Brits; instead, there are still monthly payments, more or less onerous, co-pays, and the increasing complexity and rental extraction that always comes from neoliberal market fundamentalism.) I’ve been reluctant to dig into Medicare, because heaven knows ObamaCare is enough, but prompted by alert reader DCSweeney, I’m going to give it a shot. (And I hope readers will feel free to share their own
horror stories experiences in comments.) I also hope that readers more familiar with Medicare policy than I am — many of you, I am sure — will weigh in with clarifications and commentary.
MACRA stands for “Medicare Access and CHIP Reauthorization Act,” and there’s something pleasingly meta, even a foretaste of what is to come, in the fact that “MACRA” is an acronym that includes an acronym (CHIP, Children’s Health Insurance Program). The American Hospital Assocation (not a disinterested player, but that is a topic for another post) summarizes MACRA as follows:
The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 makes sweeping changes to how Medicare will pay for physician services. The legislation repeals the flawed Medicare physician sustainable growth rate (SGR) formula and, instead, provides predictable payment increases. The law also calls for the Centers for Medicare & Medicaid Services (CMS) to implement a new two-track payment system for physicians and other eligible professionals. The intent of the two tracks is to tie an increased percentage of physician payments to outcomes through the Merit-based Incentive Payment System [MIPS] and to encourage the adoption of “alternative payment models” (APMs). APMs move payment away from fee-for-service reimbursement, and instead pay providers based on the quality and cost of care for particular episodes (e.g., bundled payment), or defined patient populations (e.g., accountable care organizations).
(MACRA is one of those “bipartisan” bills that gives you the idea that the only thing the two parties can ever agree on is screwing the rest of us.)
Note that MIPS and APMs are separate tracks, and the number of doctors put into MIPS will be an order of magnitude larger than those put into APMs. From Policy and Medicine:
Because of the high bar set to qualify for the APM track, CMS projects that only 30,000 to 90,000 clinicians will be in the APM track. An estimated 687,000 to 746,000 physicians will be in MIPS. The program will begin grading physicians in 2017 for changes in their payments starting 2019.
When we dig a little deeper, we find two major problems: (1) MIPS cannot measure what MACRA purports to incentivize, and (2) APMs are handwaving on a cargo cult level. Finally, MACRA, by further crapifying the physician’s workplace, will give doctors new reasons to leave the Medicare program (and for any good neoliberal, that’s not a bug. It’s a feature).
MIPS Cannot Measure What MACRA Purports to Incentivize
Here is the MIPS described in the language of health care policy:
Instead of applying the typical “one size fits all approach,” MACRA allows eligible professionals and eligible organizations to identify quality measures and then tailor the quality measures that best fit their individual practice and specialty. Eligible professionals are assessed only on the that apply to them, and the categories may be reweighted to compensate, as needed. Each year, the Secretary will establish a performance threshold based on the performance of all participating eligible professionals, who will be informed of how they performed in the prior period and what performance threshold they must meet to be eligible for incentive payments and to avoid penalties. Additionally, eligible professionals who [sic] fall into a high performance category will receive an additional bonus payment, and providers who make notable gains in performance will be rewarded.
If “Merit-based Incentive Payment System” makes you think of meritocracy gone mad, you’re not wrong. Focus on the two key words: “score,” and “categories.” I’ll look at each in turn.
Score: Yes, MIPS really does propose to “to provide each physician with a composite score between one and 100” for each individual doctor Of course, this is not possible. Kip Sullivan of PNHP explains:
With the exception of a few services, measuring cost and quality accurately at the individual doctor level is not possible. There are two intractable impediments: Determining which doctor patients “belong” to (the attribution problem); and adjusting measures of physician cost and quality for factors outside of physician control such as patient health status (the risk-adjustment problem). The attribution and risk-adjustment methods used today are crude even for large groups; with the possible exception of a few of the simplest process measures, they are worthless at the individual physician level.
Categories: It seems laudable that MACRA wishes to compare apples to apples when grading physicians. The difficulty comes in with categories used to determine which physicans are apples, and which are oranges, because the sharp edges of artificial taxonomies always slice through the fuzzy complexity of real-life treatment, and because the categories can be gamed.
Here’s a “wound practitioner” lamenting the MIPS taxonomy:
How are wound care specialists supposed to compete in the market as we move toward 2018? The law states payment is “based on comparative data of similar specialty in a geographic area.” So, those family-practice physicians working only in wound care will be scored and vetted against other family-practice physicians, some of whom may not be performing wound care or treating high-risk, high-cost patients. As a result, these physicians could be subject to a negative reimbursement against one’s peers, simply because CMS does not recognize wound care as a specialty based on the taxonomy identifiers. For wound care specialists, the problem exists on one base level: CMS has not adopted any methodology as of this writing to track and manage patients living with venous disease. With an annualized cost of almost $18 billion, CMS would want to track venous disease. CMS already tracks diabetic foot ulcers ($245 billion), but venous disease has seemingly slipped through the cracks.
And here’s a firm that seems to be in the business of gaming the categories:
MACRA Series – Service Codes for Primary Care: There is More Value Than You Know
1. The wellness codes (IPPE, AWVs, G0402, G0438-9). In 2005, Congress instituted the Initial Preventive Physical Exam (IPPE), the “Welcome to Medicare” service code.” This service code was designed to ensure that any patient entering Medicare was provided an opportunity to “catch up” with needed screening, disease prevention and health promotion recommendations. This service code can be used within the first calendar year of a patient’s Medicare enrollment.
2. Transitional care management codes (TCM, 99495-6): These codes were designed specifically to address patient care needs after discharge from hospital, ER observation or skilled nursing care.
(the Medicare Access and CHIP Reauthorization Act). For both, there are office workflow implications and specific roles need to be clarified and assigned. Documentation requirements are straightforward and consistent with continuity and quality patient care quality. Your electronic health record (EHR) should fully support both.
I don’t have statistics on how many doctors went into medicine so they could optimize their practice to profit from a CMS taxonomy, but my guess would be not very many. And if all this reminds you of another large-scale neoliberal debacle based on meritocratic assumptions — the “high stakes testing” regimen of No Child Left Behind — you’re not wrong about that either. Reader DCSweeney comments:
The key mechanism is reminiscent of No Child Left Behind, poor performers see their reimbursement rates cut while high performers see their reimbursements increase (+/- 9% by 2022!). The kicker is that this is zero-sum….
And all the while, the metric of “performance” is worthless. It’s as if the grades for high stakes testing were given out by throwing darts at a dartboard. And it’s going to take immense investment in paperwork for doctors to document that they’re performing to the crazypants metric! It’s a two-fer worthy of Pavlov at his best (or worst)!
APMs are Handwaving
Now let’s look at “Alternative Payment Models” (APMs). Policy and Medicine once more:
CMS proposes to establish a scoring standard for MIPS eligible clinicians participating in certain types of APMs that will by eliminating the need for such APM eligible clinicians to submit data for both MIPS and their respective APMs. CMS proposes to use the APM scoring standard for MIPs eligible clinicians in APM Entity groups participating in certain APMs that meet the criteria.
I hate even to think this, but CMS is giving the unfortunate impression that they’re making MIPS so crazypants and onerous to drive people into APMs. Then again, Kip Sullivan points out that nobody knows what an APM is anyhow, so it’s all handwaving:
[The APM program] is difficult to describe for these reasons:
- MACRA does not describe the entities that will qualify as APMs;
- MACRA sets standards for these entities that cannot be met by the vast majority of conceivable entities, including today’s most faddish APMs – ACOs and “medical homes”;
- MACRA says APMs must expose doctors to “risk above a nominal level,” but doesn’t say what “nominal” means; and
- MACRA says doctors who join APMs will earn a 5 percent bonus on revenues received through APMs, but the law fails to define “revenue” (options include revenue from Part A, Part B, Part D, all or some of those parts, or revenue received for particular services).
So, out of the crazypants MIPS frying pan into the unknown APMs fire. Not an enviable choice.
Do I have a better proposal? Yes. Burn down the entire edifice and hire some Canadians to show us how to do it right. Go with a system that’s simple, rugged, and proven. Stop paying all these people to harm us.
 And for the usual hoary old neoliberal justification. MedPage today:
Alice Rivlin, PhD, a senior fellow at the Brookings Center for Health Policy, a left-leaning [snort] think tank, called for a two-sided approach to dealing with the MACRA reforms. “We need to give patients more if we believe accountable care organizations (ACOs) or some other payment reform is promising — patients need to know they’re in [an ACO] and they have an incentive to participate in improving the cost-effectiveness of their care. And I believe we need to move more aggressively toward competition among plans, and move deliberately but not too fast toward premium support in Medicare. We could start with competitive bidding in Medicare Advantage.”
However, she added, “We need to be sure [lambert nods head vigorously] we can make competitive bidding work, and solve the risk adjustment problem, so we don’t end up … with the sickest people in traditional Medicare.
You can see the death spiral coming, right? As all the 100s leave for boutique medicine, while Joe and Jane Sixpack are trying to decide whether picking a 73 over a 68 is worth the three-hour drive and the higher deductible. Of course, Rivlin — along with the whole “skin in the game” crowd — provides an excellent proof by example that the simple rules of neoliberalism never apply to those who write those rules.